Arthritis of the Hip & Knee

"The Decision" - If painkillers and using a walking aid do not help there are no other conservative treatments that will offer any sustained benefits other than surgery. The decision to have a hip or knee replacement depends not on the X ray or the examination but on how it affects your day to day life and sleep. If your quality of life is restricted to an unacceptable level (which you will know) you should consider an operation and your GP will refer you to a specialist, who you can choose in the NHS as well as privately.

If I am going to have a joint replacement, what do I need to know?

Before the operation:
Once the decision is made you will have a pre assessment where blood will be taken, a heart tracing (ECG), swabs for MRSA and a chest X ray will be performed (It is very important to tell the staff if you are on Warfarin, Clopidogrel or Steroids). The hospital will notify you of what you need to bring when you are admitted on the day of your surgery. In particular when you are not to eat and drink from and what to do about your regular medication.

On Admission:
Your observations will be taken by the nurse, you will be seen by the anaesthetist who will discuss what type of anaesthetic he recommends for you (most frequently this will be a spinal or epidural with sedation, but general anaesthetic may be necessary if other techniques do not work or are considered not in your best interest). You will not be aware of anything. The surgeon will sign the consent form with you, put a mark on your leg and answer any other questions you have.

After the operation:
New techniques of pain relief ensure that the majority of patients will wake up in recovery with minimal pain (on the second day your pain may be greater but manageable with painkillers). If your operation is in the morning you may get up in the afternoon but definitely the next morning as will happen if the operation is in the afternoon. Do not be brave and try and avoid painkillers, they help to relax you.

Mobilisation: -
You will start walking with a frame and move quickly to crutches or sticks, guided by your physiotherapist. You will be discharged able to do stairs (dot and carry), get in and out of bed and on and off the loo. You will go home after 3-4 days with painkillers and all the aids you need (eg. raised loo seat). Discharge for both has been safely speeded up in recent years. It is rare not to be able to manage in your own home, so try not to worry.

After Discharge:
Physiotherapy is a routine after knee replacement but is decided on each individual case after a hip replacement. If you have staples or stitches (uncommon these days) they will be removed after 10-12 days at your GP practice or the hospital and it is best to keep your wound dry for 2 weeks. After this a shower is fine, but a bath should be avoided (difficulty getting in and out) for 6-8 weeks. Most patients do not require walking aids after 12 weeks.

Hip replacement:
It is within the bounds of normality to have bruising and swelling of the operated leg. The most frequent sites to experience pain are the groin, outer side of the hip and lower back (pain is rarely a major problem). Full recovery takes about 6 - 9 months.

Knee replacement:
Bruising and swelling is common. Pain can be a significant problem, particularly at night and regular painkillers are necessary and applying ice regularly can be helpful. Pain at night and burning can last several months. It is very important to work hard at getting the leg fully straight and if the knee does not bend freely to 90 degrees at 6 weeks a manipulation is advisable. Full recovery takes 12 - 18 months.

Frequently Asked Questions

When can I resume normal activities: guidelines can be given but there is considerable individual variation especially if you have other medical conditions, particularly if they have an affect on your balance or your other joints.

- A good guideline for driving is 6 weeks but 4 - 8 weeks is a balanced range.

- Climbing the stairs with a normal walking pattern varies enormously but 75% - 80% of people will achieve this by 12 weeks.

- Showering from 2 weeks but bathing is slower due to the challenges of getting in and out! A waterproof dressing can be used before this but must be sealed.

- Hydrotherapy or using a pool is an advantage from 2 weeks but swimming especially breaststroke is probably uncommon before 12 weeks.

- Using a gym, eg. exercise bicycle, from 4-6 weeks is fine but the range of movement after knee replacement may delay this.

- 80% of people forget for large periods of time their hip replacement but this is the exception in knee replacement.

- It is also unusual after knee replacement to be totally free of any discomfort as aching, especially over the front of the knee is common. It is important with a knee replacement to accept that it is likely to be a success if you have realistic expectations. Walking with much less pain on a stable base is the main aim.

- Kneeling is possible after knee replacement but is best kept to a minimum and then on soft surfaces or a kneeling pad.

- Whereas tennis and skiing are frequent after hip replacement they are a bonus and not to be expected after knee replacement. Golf is a very reasonable expectation after both hip and knee replacement.

- There is no evidence the type of replacement (total hip or knee) or the size of the incision make any difference to the outcome.

- Partial knee replacements give very good functional results with increased range of movement and reportedly may feel more like your own knee.

When can I drive? When can I fly? When can I resume activities?

When can I drive? is the most frequently asked question by patients because it is critical for the running of everyday life; eg. I need to drive to work, I have to do the school run etc.

However when can I fly? is increasingly common with ever more frequent business travel and international holidays.

Driving:
There are no hard and fast rules regarding the resumption of driving from the police, insurance companies or clinicians but the final responsibility lies with the patient where "common sense" is the ultimate guide. There have been a number of studies which have measured the total braking time (BRT) and the Brake Pedal Force (BPF). This is all very technical but the ability to perform an "emergency stop" is a very good assessment of readiness and safety for driving.

The DVLA (Driving Vehicle and Licensing Authority) regulates standards for driving and has extensive guidance for many common medical conditions but states "If you have a broken limb you do not need to tell the DVLA about it". Doctors do not have to notify the DVLA unless driving is restricted for in excess of three months. The DVLA overall recommends a balanced decision between the doctor and patient and that the patient notifies their insurance company.

Ultimately the DVLA says the driver is in control of the vehicle and should be able to demonstrate this to the police.

My recommendations for driving would be:

- Notify your insurance company before you resume driving after major surgery.

- If you have an automatic car and have had surgery on your left leg you may be able to resume driving earlier.

- DO NOT with an automatic car try and cheat by using your left leg if you have surgery on your right leg.

- The first time you drive ensure the roads are quiet so you can be sure you are confident. If you have any doubt take someone with you or don't do it.

- Arthroscopy of the Knee: 3-5 days depending on individual
assessment/common sense.

- Ankle Fractures: 2 weeks after removal of plaster.

Flying:
There has been much publicity surrounding the risk of thrombosis and air travel. The risk expressed in the media may be over emphasised but erring on the side of caution is advisable.

Short haul flights (guidelines):
Ideally avoid flying for 6 weeks.

If necessary inside 6 weeks: (a) Minor surgery - wear flight stockings, avoid alcohol, drink water and keep your ankles moving. (b) Major surgery - this is a balanced decision with your specialist or GP but the measures in (a) plus the use of a blood thinning agent may be advisable.

Long haul flights (guidelines):
1. If necessary before 12 weeks the measures in (a) above and I personally would recommend taking a blood thinning agent recommended by your specialist or doctor.

2. If after 12 weeks the guidelines in (a) above are sensible.

Resuming Activity (Sporting or otherwise): There are too many options to consider here but some useful rules of thumb are:

- You can ride an exercise bicycle when your confidence allows or your knee bends sufficiently.

- As a general rule after knee surgery non weight bearing exercises eg. exercise cycles, rowing machines are a good starting point.

- You can ride a normal bicycle when you can walk confidently without walking aids and you feel your balance is good. You need to be able to stop quickly!

- Reintroduce golf and tennis from 3 months as confidence allows after major surgery.

- Skiing and tennis are common activities after hip replacement but should be considered a bonus after knee replacement. Golf is normal after both. A pain killer or anti inflammatory can help ease you back into sport.

- Wearing a brace after ligament reconstruction to resume sport is predominantly for confidence.

- Contact sports and those necessitating rapid changes of direction should be avoided for 6 months after knee ligament reconstruction (physiotherapist will provide further guidance).

- After hip and knee replacement in particular, your safety and confidence are paramount so be guided by how you feel NOT what other people tell you, you should be doing or what someone else was doing at the same stage.

- After hip and knee replacement procedures let nature take its course rather than set yourself specific targets. Your body will tell you if a particular activity feels right!

- Do not be nervous about using painkillers as you will almost certainly not be masking any serious underlying problems and they do help your recovery. Painkillers will not mask serious problems.

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